Elderly and Poor with Limited Options

The 2013 , which was intended to provide long term care insurance to millions of participating Americans, means that affordable financing of long term care insurance remains out of reach for many. Currently, the bulk of nursing home care is reimbursed by Medicaid or Medicare payments, with Medicaid doing most of the heavy lifting. Medicaid also provides the lowest reimbursement rates in the nursing home sector, setting the stage for disparities in access to quality long-term care quality.

Source: sima dimitric (Flcikr/CC)

Source: sima dimitric (Flcikr/CC)

“Dual eligibles”—those who are eligible for Medicare and Medicaid—are already more likely than non-dual eligibles to reside in low quality nursing homes. They are also considered an at risk population: they are more likely than other Medicare beneficiaries to be poor, have less than a high school education, be in fair or poor health, or be members of a minority group.

Recent research reported in Health Affairs explored the relationship between public reporting of nursing home quality and disparities by examining how the Centers for Medicare and Medicaid Services’ five star rating system for nursing homes affected residents who are dually enrolled in The authors hypothesized that dual eligibles would benefit less than non-dual eligibles from the introduction of the rating system.

The study findings support the hypothesis. In an enormous sample of 5,591,356 residents residing in 15,894 nursing homes, dual eligibles were 4% more likely to reside in a one star home, and 1.5% less likely to reside in a five star home (p< 0.01). The study also found that the benefit of the five star system to dual eligibles was largely due to providers improving their ratings, not consumers choosing different providers.

The authors posit that dual eligibles benefit less from public reporting of nursing home quality for two main reasons: persons of lower socioeconomic status may live a great distance from a highly rated nursing home, and they may not be able to access a Medicaid bed in a high quality home. The article concludes by suggesting an increase in Medicaid payment rates or replacement of Medicaid with a national insurance system for long term care. Providing incentives for low rated nursing homes to improve quality ratings is, of course, more feasible. We could, however, shift the burden to Medicare, thus relieving state budgets.

commentary by Megan Doede, RN, MSN, CEN

Abstract

Market-based reforms in health care, such as public reporting of quality, may inadvertently exacerbate disparities. We examined how the Centers for Medicare and Medicare Services’ five-star rating system for nursing homes has affected residents who are dually enrolled in Medicare and Medicaid (“dual eligibles”), a particularly vulnerable and disadvantaged population. Specifically, we assessed the extent to which dual eligibles and non-dual eligibles avoided the lowest-rated nursing homes and chose the highest-rated homes once the five-star rating system began, in late 2008. We found that both populations resided in better-quality homes over time but that by 2010 the increased likelihood of choosing the highest-rated homes was substantially smaller for dual eligibles than for non-dual eligibles. Thus, the gap in quality, as measured by a nursing home’s star rating, grew over time. Furthermore, we found that the benefit of the five-star system to dual eligibles was largely due to providers’ improving their ratings, not to consumers’ choosing different providers. We present evidence suggesting that supply constraints play a role in limiting dual eligibles’ responses to quality ratings, since high-quality providers tend to be located close to relatively affluent areas. Increases in Medicaid payment rates for nursing home services may be the only long-term solution. PMID: 25941284.

Konetzka R, Tamara et al. Health Aff. 2015; 34 (5): 819-27.